National Health Service (Charges and Pharmaceutical and Local Pharmaceutical Services) (Coronavirus) (Amendment) Regulations 2021
(3 years, 7 months ago)
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Lord Hunt of Kings Heath
That this House regrets that the National Health Service (Charges and Pharmaceutical and Local Pharmaceutical Services) (Coronavirus) (Amendment) Regulations 2021 (SI 2021/169) do not address the underlying funding problems faced by the pharmaceutical sector, which may affect the capacity of local pharmaceutical services to respond to future emergencies.
Relevant document: 47th Report from the Secondary Legislation Scrutiny Committee
Lord Hunt of Kings Heath (Lab) [V]
My Lords, I welcome and support this statutory instrument. In fact, it is an excellent example of the contribution and innovation that community pharmacies make. Disappointingly, this has not always been recognised by the NHS, nor financially supported by the Government. As the Pharmaceutical Services Negotiating Committee has pointed out, community pharmacies have remained open throughout the Covid-19 pandemic; they have adapted to provide services in a Covid-secure way for their local communities, and they are offering face-to-face advice and healthcare on a walk-in basis. As well as delivering more than 1 billion prescription items a year, they have delivered healthcare advice at the rate of more than 48 million consultations a year. They have been a buffer for the NHS, helping their local communities and reducing pressure on other NHS healthcare providers.
The PSNC audit earlier this year, to be published this week, is fascinating. It says that 1.1 million informal consultations are taking place in community pharmacies in England every week. That comes to more than 58 million consultations a year. Every week, pharmacies provide advice on symptoms to more than 730,000 people. Nearly 38 million people per year—76% of pharmacy advice consultations—are people who have self-referred into the community, and 8.6% of those people seeking such advice said that they had been unable to access another part of the healthcare system. One in four informal consultations in pharmacies also involves advice and support relating to Covid-19. That means that 270,000 patients every week are seeking advice from pharmacies on Covid. Pharmacies giving advice save more than 2 million GP appointments every month, or 24 million every year. An additional 70,000 people would go to A&E or an NHS walk-in centre every week if they could not get advice from their local pharmacy.
Pharmacies, therefore, make a huge contribution. They can also make a contribution to the national Covid-19 vaccination effort. Some community pharmacies are already doing so, but all of this impressive work is at risk if they are not given adequate financial support. They cannot be expected to subsidise the NHS.
Work by the Company Chemists’ Association has shown that the community pharmacy sector is facing a real-terms cut in funding of more than 25% during the period 2014 to 2024. In 2016-17, funding for pharmacies was cut by more than £200 million a year, and, as a direct consequence, community pharmacies of all sizes have closed. We are now two years into the current five-year community pharmacy contractual framework, which was due for an annual review last year but which did not take place due to Covid. So the sector has been left, after those cuts, with a flat funding position for five years in a row, when the cost of service delivery continues to rise and the NHS prescribes more medicines year after year. We know that the additional cost of providing Covid-safe care has been significant. The sector has spent more than £400 million extra—out-of-pocket expenses—to sustain the service. The Government have provided some extra funding, but this falls way short of covering the full costs incurred.
The systematic underfunding of the community pharmacy sector, combined with the pressures to which I have referred, is putting many pharmacy businesses in a critical position. Many pharmacy owners are having to reduce services, opening hours or staff levels to cut down on costs. Large pharmacy chains have also announced significant cost-cutting and reorganisation measures over the past year. A study of independent community pharmacies found that 28% to 38% were in financial deficit already, and that this would rise to 64% to 85% without a funding uplift.
Already, we have also seen more than 400 net closures of pharmacies since funding cuts were introduced in 2016; 327 of them have been in the 30% most deprived areas. This has a knock-on effect on local high streets and potentially contributes to growing health inequalities. It is surely counterintuitive that we should have pharmacies closing in the middle of a pandemic—but without funding support, we expect more closures, which means more communities losing their primary link to the NHS.
The Government did provide £370 million in emergency funding loans to help pharmacies to stay open during the pandemic, in 2020. As I have explained, that money has been spent on covering the more than £400 million of NHS costs. Cash-flow modelling suggests many pharmacies cannot afford to pay back these emergency moneys. In summer 2020, HM Treasury made an initial offer on reimbursing pharmacy costs throughout the pandemic, but this was very constrained. Will the Minister tell us today whether the Government will write off the £370 million in advance payments that were made to pharmacies at the beginning of the crisis? I hope that he can bring a positive message. This would go some way to bridging the cost gap. Importantly, any shift to claw back this advance money from an already underfunded network will lead to further financial difficulties and potential closures.
I opened by describing some of the fantastic work done by community pharmacies. They are a critical part of the NHS and they have much more to offer to benefit patients, local communities and local healthcare systems. They are working with local GPs to roll out referrals from general practice, so that patients can get quick and convenient access to advice on minor illness, but they could do so much more. Over the coming months and years, pharmacies could really help on prevention, on levelling-up health inequalities, on identifying people with undiagnosed high blood pressure and other cardiovascular diseases, and on helping to tackle obesity and other health factors that have contributed to the UK Covid-19 death rate. They could provide enhanced community and public healthcare. I have already said that they could boost our vaccination effort and provide a first port of call to support GPs to return to pre-Covid activities. The new community pharmacy consultation service has the potential to enable pharmacies to meet the currently unmet need in urgent care, but it is currently failing due to a lack of engagement by, and referrals from, GPs and NHS 111.
It is very important that, in addition to providing financial support to the sector, the NHS trusts patients to know when their pharmacy is the right place for them to receive their care. Patients should be allowed to choose pharmacy as a place to receive their urgent NHS care. Part of the problem is that community pharmacy does not have a place around the table when it comes to the decision-making bodies at local level. I give notice to the Minister that I expect the NHS Bill, which we will see in the next Session, to put this right. We argued when the Bill went through that removing pharmacy from the boards of CCGs was a mistake. My goodness me, it has been a mistake.
Surely we should all come together to unlock the potential of community pharmacies and help the NHS get back on its feet as quickly as possible. I come back to funding: the current funding envelope for the community pharmacy network is unsustainable. We need to do better. The NHS could learn and benefit hugely from the pharmaceutical sector. I hope that this debate will encourage the Minister to take a much more positive look at what the sector can provide. I beg to move.
Baroness Barker (LD)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for introducing this debate. It is a most timely and important one. As I sat down to prepare my speech for today, I thought back to a year ago, and two places. One was the relatively affluent suburb of south London where I live. It is very fortunate. It has a major teaching hospital, a number of excellent primary care facilities and, if anything, an oversupply of pharmacies, both chain and independent. Contrast that to a small place up in Lancashire, where there is a district general hospital but where the GP services have not had any permanent staff for the whole population of a small town in over 15 years. The high street chain pharmacies there have bailed out and just one or two community pharmacies remain, and they are struggling.
From watching people at that time when it was not possible either to go to hospital or to a GP, I saw people visiting their local pharmacy services and relying on them. In south London they were very well served; up in Lancashire they were not. That is the important thing for the Government to recognise. We are talking about a sector that is both a key part of the front-line delivery of healthcare services but also, in part, part of the retail sector, which we know was under severe stress even before the events of the last year. It behoves the Government to take a strategic view of services for the public and to begin to work out exactly how we make sure that the population as a whole has access to this most important of services.
I am no Pollyanna about the pandemic. I do not take the view that there are any great silver linings. It was terrible. However, the pandemic has highlighted those things that are contributing factors to health inequalities as well as new ways of working for the NHS which we need to—and have shown in the last year that sometimes we can—adapt and accelerate at pace.
The important thing to understand is the unique role of high street pharmacies. They are not on the web. They are physical presences where people can go as a walk-in and talk to trained professionals. That, I believe, makes pharmacies a very significant part of the overall pattern of health provision, which I think may change. I think the way in which people will access GP services in future may change. However, we have to have some consistency and some understanding on the part of the public, who, by now, after a year, are very well versed in understanding how we best use the resources of the NHS and do not waste them but who really want to be sure that they can use pharmacy services and can rely on them to be there.
The all-party parliamentary group held an inquiry in 2020. We have known since 2016 that we have lost about 400 pharmacies, disproportionately in those poorest communities. In 2020 we found that the cost of staying open and offering services when other NHS services were under the cosh has had a disproportionate effect on pharmacies. Some 95% of independent pharmacies believe that they are under financial pressure. We really should not allow that to continue.
I also want to talk about the distinction between community pharmacies and the chains. Chain pharmacies have a difference that arises from their ability to operate at scale and that is very valuable. It is now the case that the majority of people with eye problems go to their opticians. I know that in this last year GPs were signposting people to go to opticians if they had minor eye problems; so, too, with audiology services and other services which are primarily being done in pharmacies rather than in the NHS. If that works effectively and efficiently for people, we should make sure that it remains.
I am the co-chair of the All-Party Parliamentary Group on Sexual and Reproductive Health. One of the biggest changes that we have witnessed during the pandemic is the change to telemedicine for women seeking abortion and access to contraceptive services. Data that has been subject to two different reviews—in Scotland and England—shows that that move has been extremely beneficial to patients. It has cut waiting times. It has enabled women to be seen much more quickly than they would otherwise have been. It has beneficial health outcomes. I know the Government are in the middle of a consultation but I hope that they will make that move permanent simply because it is in the best interests of the health of women and girls. I also hope that the Government will come through on the suggestion that we should make access to contraception much easier and allow young women to go to pharmacists and for that to be the primary route for accessing oral contraception but that the oral contraception should be free. We should not be cost shifting as we do that.
I want to make one other point. It has always seemed to me that one of the biggest barriers to integrated healthcare care at whatever level—acute, primary, community—is that of information and data sharing. I believe that if we are to make more progress on that—as I think has been hinted at or has been mentioned in passing in the White Paper—we need to come back to how data is shared responsibly across different providers so that we can enable people to have access to services without any leaking of their private data. I believe it is safer for people to have their data shared with NHS-approved pharmacists than it would be for them to seek other services on the web from unlicensed providers.
I want to echo the views of the noble Lord, Lord Hunt of Kings Heath: pharmacies have played a tremendous role this last year, but they cannot sustain it and continue to provide the services that they have. If we imagine that, this time next year, the NHS is again having to deliver a vaccination programme on the scale that it is now, it is impossible to think that pharmacies could continue to bring up the slack. So in the meantime, I back the noble Lord, Lord Hunt, in his request that pharmacies are not asked to return the £370 million that was put in on an emergency basis, and that, secondly, as a matter of urgency, we have a plan for integrating pharmacy services in a clear and thought-out way, proactively taking part in prevention and also enabling people to deliver emergency front-line telemedicine services to people who need acute access.
Baroness McIntosh of Pickering (Con)
My Lords, I start by declaring my interest with the Dispensing Doctors’ Association, as in the register of Members’ interests.
I welcome the regulations before us this afternoon; the instrument makes a permanent change to broaden the existing arrangements for the supply of prescription items for pandemic disease or in other serious emergencies. As indicated by the Secondary Legislation Scrutiny Committee, there really are no downsides to this. The instrument
“allows specified medicines to be issued free of charge either on prescription or in response to a patient group direction (PGD), a pandemic treatment protocol (PTP) or serious shortage protocol (SSP) authorised by the Department for Health and Social Care.”
I welcome the opportunity to discuss the regulations before us. I also pay tribute to the role that community pharmacies have played in this regard—both generally and particularly during the pandemic. I would link to the role of community pharmacies the particular role that dispensing doctors have played. I once again ask my noble friend the Minister if, in the course of the afternoon, we could focus particularly on delivering medical care and pharmaceuticals in a rural setting, and ensuring that all aspects of rural life, including health policy, are delivered in a way which has clearly been rural-proofed.
I am delighted to join the noble Lord, Lord Hunt, and the noble Baroness, Lady Barker, in paying tribute to the role that community pharmacies play. But I would also like to pause for a moment and set out, as is referred to in the Explanatory Memorandum, the role that dispensing doctors have played. This is something of a lifelong interest for me because my late father was a dispensing doctor and my brother is a retired dispensing doctor. Dispensing doctors exist in rural areas because a pharmacy is not commercially viable. They date back to the time of Lloyd George and the National Insurance Act 1911.
It is important to appreciate that the income from dispensing cross-subsidises the medical service. Dispensing doctors do not have access to EPS—electronic prescription services—for their dispensing patients, over a decade since the system was introduced. That would seem to be a sign that perhaps rural-proofing in England is not working as well as it is in Wales, where they will be included for dispensing patients. Pharmaceutical needs assessment can place a dispensary under threat if a pharmacy application is made, unlike in Wales, where dispensing doctors are a full part of the pharmaceutical service, thanks to the Welsh department listening to the actions requested by the Dispensing Doctors’ Association.
Dispensing doctors are buying drugs in the same marketplace as pharmacies, yet their system of reimbursement and fees are different from community pharmacy. Despite this, as I understand it, NHS England and the department exclude dispensing doctors—in particular the DDA—from discussions on these matters. I ask my noble friend: why is that the case? The noble Lord, Lord Hunt, also mentioned that community pharmacies are excluded from these decisions as well. It strikes me that, immediately, the DDA, representing dispensing doctors and community pharmacies, should be at the table when these matters are discussed.
Most dispensing practices have vaccinated their patients against Covid as there is no scope for large centres in remote and rural communities. It is extremely difficult in areas such as sparsely populated parts of north Yorkshire for patients to access any such urban remote centre. Also, a lack of rural proofing harms rural communities. Primary care networks are being set up yet most dispensing practices are, in effect, their own primary care network given the large practice areas and dispersed populations that they serve.
As I mentioned previously, dispensing doctors are NHS GPs who are permitted to dispense medicines in designated rural areas where a community pharmacy is not economically viable. As I also said previously, dispensing practices use any profits that they make from the purchase of the drugs that they dispense to cross-subsidise the provision of the medical practice. That is often overlooked. There has never been any formal acknowledgement of this in England, although I understand that Scottish officials have done so before the Scottish Parliament.
In making the specific request to have regard the role of dispensing practices as well as community pharmacies in the dispensing of drugs under the regulations before us this afternoon, may I make a more general request to my noble friend that his department practise proper rural proofing? This will ensure that the work of, and reimbursement of, dispensing doctors in dispensing to their patients—often in rural, remote and sparsely populated areas—is properly addressed in the terms I have set out.
In that regard, I shall support the Motion to Regret before us this afternoon if the noble Lord, Lord Hunt, presses it to a vote. I hope that my noble friend the Minister will look sympathetically on the arguments I have made in favour of dispensing doctors specifically and the rural proofing of health policy more generally.
Baroness Wheatcroft (CB) [V]
My Lords, as others have said, community pharmacies make a huge contribution to life in the UK. I support this narrow statutory instrument but I deplore the position in which so many pharmacies have been left.
Let us look at what community pharmacies do and what they could do. They already take a huge weight off GPs and the accident and emergency services, effectively providing a triage service in many cases but often dealing with the problem all the way through. They provide emergency out-of-hours services, particularly for those who are terminally ill and need special medication, perhaps at night when other services are shut. They provide screening services, which are essential if we are to keep our population on the right side of healthy. They deal with minor ailments. They provide obesity management, which we all know is absolutely crucial for the future. They also provide phlebotomy, taking quite a lot of the effort of blood tests out of hospitals, which are so overstretched at the moment. They can provide stop smoking clinics; again, these are essential for modern life, where we need to kill tobacco before it kills people.
As we have seen in the past 18 months, pharmacies can also provide vaccination services. This is going to be increasingly important because it appears that vaccination is going to be not a matter of getting through this particular Covid epidemic but an annual event. We will need all the vaccinators we can find. How much more could our community pharmacies do?
If ever we are to see the combination of health and social care that has long been seen as the holy grail for a healthy, comfortable and happy society, community pharmacies must be a crucial part of it. They can straddle the ground where local government and the NHS meet. They can broker understanding and they can broker solutions, to make it sensible, convenient and comfortable for people to live in the community, rather than being sidelined in homes. But what is happening to those pharmacies? The EY report published last September, commissioned by the National Pharmacy Association, found that the current network in England is
“unsustainable under the current financial framework”.
EY projected that by 2024, 72% of pharmacies will be in deficit, with an overall shortfall to the sector of £43,000 on average to each pharmacy and concluded that no industry is sustainable with so many operators in default. Already 28% to 30% are in default and, according to the survey, 52% are planning to sell their businesses. If the businesses are in deficit, there will not be people queueing up to buy them, yet a hit of 52% to our network of community pharmacies would be completely disastrous. The National Pharmacy Association, which commissioned the survey, called on the Government to take a “public interest focused safeguards” approach against the pharmacy network collapsing. Can the Minister commit to re-examining the funding model with that public interest safeguard central to the thinking?
Pharmacists undergo long training and bring vast medical expertise to their dispensing role, but they dispense far more than just medicines. They are there to provide advice and they offer humanity. For many elderly people, the visit to the pharmacy is one of the major points of contact with human beings during their week. They provide centres for communities. In many cases, they are core to the continued survival of a viable high street.
We have seen so many shops closing due to Covid and not reopening. The trend was already under way with internet shopping, but it has been exacerbated by the virus. In many cases, however, the community pharmacy continues to draw people into an area and therefore provide footfall to sustain the other shops and cafés which bring life to an area. They do not have the type of footfall that appeals to the major chains. In many cases, the major chains have a business model that depends on large sales of make-up, toiletries, photographic equipment—you name it. That is what keeps them trading, while the pharmacy just draws a few extra customers into the business. However, the pharmacies that are hubs to so many communities have only minor add-on sales. They are at the heart of the communities because they provide an essential service to the people who live locally. If those streets are to survive, they need the pharmacies to survive.
Therefore, while I support this statutory instrument, I also support the call from the noble Lord, Lord Hunt, for the Government to re-examine the funding and to make a short-term £350 million improvement to the way these pharmacies survive; otherwise they will simply die in front of us, and we cannot afford to see that happen. Already, the Government have indicated that they would prefer to use a firm such as Greensill to provide these pharmacies with the speedy payments that they need, rather than speeding up the payment itself. So many pharmacies had to opt to use that service because they needed the cash flow immediately and could not wait for the Government to pay their bills. Those who have tried to sign up since the middle of March have been unable to. Therefore, my final question not the Minister is: can he undertake to ensure that the Government pay pharmacies promptly for the service that they provide, so that they do not have to resort to external factors to get their money on time?
Baroness Brinton (LD) [V]
My Lords, I thank the noble Lord, Lord Hunt, for tabling this regret Motion. I echo his opening remarks about supporting the principles set out in the regulations, but proper resources are needed.
We on these Benches thank the All-Party Pharmacy Group, the Company Chemists’ Association, the Pharmaceutical Services Negotiating Committee and the Library for their excellent briefings. I personally want to thank my local community pharmacy for the wise advice that it provides for my community and its ability to provide excellent services over the last 14 months, since the start of the pandemic.
A bit of housekeeping first: I note with regret that this instrument breaches the 21-day rule and its provisions came into force on 1 March 2021. The noble Baroness, Lady Thornton, and I often say to the Minister: when will this urgency rule change? I understand that there are some issues about really urgent statutory instruments coming in on time, but this one should have been advertised in advance and ready for us to debate before it came into effect. Is it so inconceivable to think that, a year into the pandemic, we might have wanted to plan for a place to redistribute new medicines urgently? The Government are far too reactive, and they really need to plan. So how have the Government been working with pharmacies throughout the last year on this issue?
It is interesting to note that the Explanatory Memorandum says that the 2021 regulations also make changes to existing legislation on the obligations of different types of pharmacy. As a result, certain types of providers of community pharmacy services will be required to provide a home delivery option for patients with specific prescription items in a pandemic situation free of charge. We have heard from a lot of community pharmacies that are struggling financially, and they may not have the ability or finances to set up a delivery system of that kind. So how are the Government working with pharmacies to ensure that they have the proper resources to deliver medicines to vulnerable patients?
I believe we all recognise that community pharmacies play a vital role in their local areas—often extremely local—which gives them the ability to reach right into the communities, something that is much harder for many other healthcare providers to do. Whether they are in a town centre, a member of a large pharmacy chain or a family-owned pharmacy at the heart of their village or ward community, our pharmacies are an essential tool in reaching everyone. However, we need to note that since 2016 we have lost 400 pharmacies —perhaps not surprisingly, disproportionately from the poorest communities with the largest health inequalities, as my noble friend Lady Barker so movingly described. Thinking about the Government’s focus on health inequalities, community pharmacies in those areas absolutely need the right resources.
The All-Party Pharmacy Group ran an inquiry last November that included a survey of just over 1,600 pharmacy professionals in England and called for written and oral evidence. It found that the cost of staying open throughout the pandemic and offering services when other NHS services were reduced or halted resulted in staff burnout and rising debts. We hear a lot about nurses, doctors and front-line hospital staff but we need to recognise that other healthcare professionals have faced that same burnout.
Nearly half of pharmacy contractors think that their pharmacy is at risk of closing within the year. More than nine out of 10 feel that their place of work is under financial pressure, and over nine out of 10 feel that the Government do not appreciate the role of pharmacies in front-line healthcare. Pharmacies dispense 1 billion prescriptions a year and gave more than 2 million flu vaccinations last winter. Pharmacists are highly trained healthcare professionals, and their pharmacies are the front door of the NHS for many people who may be too scared or just do not know where to take their health issue.
Pharmacists deliver advice via 48 million consultations a year, taking vital pressure off our GP surgeries, urgent care centres and accident and emergency services, as outlined by the noble Baroness, Lady Wheatcroft. They have also moved with the digital times with a confidence and ease that some other parts of the NHS might perhaps envy—for example, with electronic prescriptions sent from surgery to pharmacy and digital notifications letting the patient know when they can collect their prescriptions. During lockdown, they have worked with volunteers to deliver prescriptions to people who cannot leave home, whether they are shielding, self-isolating or quarantining. More importantly, their Pinnacle database was used by the NHS to record Covid vaccines delivered, and then linked back to NHS records. It is very welcome that our pharmacists had an effective system, and that the Government, for once, recognised that it would be faster and more effective to use an existing system. I hope that joint working is symbolic of the esteem in which the Government and the NHS hold our pharmacies.
They have done all this without complaining, repeatedly finding ways to make things happen, especially in the last year, and we know that they are trusted by their customers. However, overwhelming financial pressures are causing them serious concern. As we have heard, many pharmacies are being pushed to the brink of closure. An EY report published last September made it absolutely plain that the community pharmacy network is unsustainable under the current financial framework, predicting that, without any change, 72% of pharmacies will be in deficit by 2024, with a network-wide deficit of just under £500 million.
These financial projections were based on figures that predated the pandemic, which has undoubtedly put further pressure on pharmacies. This extra pressure means that nearly half our community pharmacists believe that their pharmacy is at risk of closing within the year. The problem is that the regulations take no account of these circumstances. Can the Minister tell us when the Government and the NHS will consult with pharmacists so that they have a clear picture of what is happening? When will the Government and the NHS turn that into urgent recommendations for structural financial change? Enhanced resources would make sure that pharmacies are able to be at the heart of any health reforms that the Government wish to announce following their White Paper. Will the Government look specifically at providing resources for training pharmacists to deliver the new community health services that Ministers refer to so frequently?
At this difficult time, pharmacies are also being asked to pay back the advanced funding provided by the Government to help deal with the extra demands relating to Covid-19, but we know that much of this funding did not even cover the extra costs that pharmacies have had to bear. With their other financial problems, as already outlined, plus extra costs not supported by government, many pharmacists will not even be able to make these repayments. If the Government do not relax the repayment timing—or, better still, turn these loans into grants—forcing repayments now may force pharmacies into closure. That would be catastrophic, and a heavy burden for any Government to bear, especially one that has dished out billions of non-repayable grants to many other small businesses, which is what most of our community pharmacies are.
The pharmacy sector is willing and able to step up and help transform health services. The Company Chemists’ Association said on publication today of the Government’s White Paper:
“We hope the proposed changes in this White Paper will create an environment that allows the community pharmacy sector to do more to help relieve pressure within the rest of the NHS. With waiting times for hospital treatment at their highest for ten years, community pharmacies are needed now more than ever to provide patients with clinical care, close to home.”
It went on:
“However, to deliver on this, pharmacies need fair funding for both the services they currently provide and for any additional workload they are ready and willing to deliver.”
Along with the noble Lord, Lord Hunt, I welcome the principles behind these regulations but, without appropriate support and resources, the Government are setting our pharmacies up to fail—something no one in Parliament or government wants to happen. I look forward to the Minister’s response.
Baroness Thornton (Lab)
Like my noble friend Lord Hunt, I welcome the purpose of the 2021 regulations, as community pharmacies are contracted and commissioned in England under the national community pharmacy contractual framework, which sets out the services that need to be provided, how quality is assured and other expectations, such as safety.
As has been said, the CPCF is negotiated nationally between NHS England and NHS Improvement, the Department of Health and Social Care, and the Pharmaceutical Services Negotiating Committee. As has also been said, the latest CPCF runs from 2019-20 to 2023-24, but it has not been able to be reviewed, due to Covid. It makes it easier for pharmacies to dispense certain medicines under specific circumstances. If those medications to help treat coronavirus outside hospitals are found, the regulations aim to allow them to be dispensed in such a way as to maximise take-up—this must be the right thing to do.
Community pharmacies makes up one of the four pillars of our primary care system in England, along with general practice, optical services and dentistry. They must often feel that they are the poor relation—the wonky leg on this particular table, perhaps. I will not list all the contributions that they make to our primary healthcare system because that has been adequately covered by many speakers—in fact, all of them, in different ways—in this debate. They are an important feature and fixture on our high streets, in our rural communities and, often, in our supermarkets.
When Covid struck, community pharmacies did not close; they stayed open and served their communities. They continued to deliver medication to people who could not leave their homes. They have been a huge asset to our NHS throughout this whole period; they have been vital. We depend on them at a local level, in both rural and inner-city communities; as people have said, their expertise saves hundreds of thousands of GP and hospital visits. Indeed, the Government have encouraged people to go to their pharmacy before they do anything else—quite rightly.
I support the housekeeping point made by the noble Baroness, Lady Brinton, about the instrument breaching the 21-day rule, with its provisions coming into place before that. The noble Lord knows that a bit of forward planning would be appreciated, but I do not deny it is clear that, because of the rollout of the vaccine, it was necessary to ensure that no one paid for their vaccine, or any treatment in another pandemic situation, to support the maximum take-up of treatment.
However, why would the Government underfund and behave in such a fashion as to undermine and put at risk these businesses? That is the basis for my noble friend’s regret Motion. I have a further question about the uncertainty over the hub and spoke proposals that were in the recent MMD Act: does the Minister have an update on how implementation work is progressing and when we can expect the consultation process to commence?
I finish by asking three questions. Can the Minister advise the House when community pharmacies can expect a final decision on the reimbursement of their extra Covid costs? Like the noble Baroness, Lady Wheatcroft, I agree that the likes of Greensill are not an answer to this. Can the Minister explain why the NHS is refusing to increase investment in community pharmacies to support the NHS? Given the vital role they play, as everybody has acknowledged in this debate, they need certainty about their ability to play their full part in tackling the Covid healthcare backlog, for example. Finally, would the Minister willing to meet me, my noble friend Lord Hunt, other noble Lords, and representatives of pharmacy associations, for instance the Company Chemists’ Association, to discuss long-term funding for this sector?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for tabling the Motion on this topic. I also take this opportunity to express our profound thanks to community pharmacies. The noble Lord, Lord Hunt, put it extremely well. They are an absolutely key part of our NHS family, and they have risen monumentally to the many challenges brought by this pandemic. Community pharmacies adapted early to working in a Covid-secure way. As has been noted earlier, they stayed open and continued to serve their communities by providing vital pharmaceutical services, typically one billion prescriptions per year. My noble friend Lady McIntosh put it very well; they absolutely stepped up when needed, including by opening on bank holidays, implementing a medicines delivery service and, more recently, as part of the Covid-19 vaccination programme and the lateral flow distribution service Pharmacy Collect.
Pharmacies are a trusted resource at the heart of our communities, an easily accessible part of the NHS, and are highly rated by the public. I am saddened by the Motion which expresses regret that the National Health Service (Charges and Pharmaceutical and Local Pharmaceutical Services)(Coronavirus)(Amendment) Regulations 2021 do not address the funding problems faced by community pharmacies. This statutory instrument amends existing legislation to ensure that if a treatment for Covid-19 or another pandemic disease is identified as suitable for use outside hospitals, it can be accessed easily and by as many people as possible without needing to pay a prescription charge or to go to a pharmacy. I assure the noble Baroness, Lady Brinton, that pharmacy contractors will be remunerated for the services in question. Fees for these services, as always, are subject to negotiations with the Pharmaceutical Services Negotiating Committee.
Noble Lord will recall, I hope, that in July 2019 a landmark five-year deal was agreed with the sector—the community pharmacy contractual framework. This deal commits almost £2.6 billion each year to community pharmacy. It is a joint vision of the Government, NHS England and the PSNC for how community pharmacy will support delivery of the NHS long-term plan. Over the period of the five-year deal, community pharmacy will be more integrated into the NHS, deliver more clinical services and become the first port of call for many minor illnesses. This will take pressure off other parts of the NHS, as has been noted by noble Lords. Good progress is already being made on this journey. For example, since 2019 NHS 111 has been able to refer patients to a community pharmacist for minor illness or for the urgent supply of a prescribed medicine. At the end of last year, we extended the service to GP surgeries, which can now also formally refer patients to community pharmacy for consultation. We are exploring extending this service to other parts of the NHS. We also recently introduced the discharge medicine service, enabling hospitals to refer discharged patients to a community pharmacist for support with their medicines. I expect more services to be introduced in the new financial year.
I am very well aware of the pressure that community pharmacists are under, like much of the NHS, particularly during the pandemic. Throughout the pandemic, the Government have worked with community pharmacy, putting in place a comprehensive package of support for the sector. Most community pharmacies have been able to access general Covid-19 business support, including business rate relief, and retail, leisure, and hospitality grants. We estimate that community pharmacies have had access to some £82 million in grants.
We have provided extra funding for bank holiday openings and the medicines delivery service for shielded patients and a contribution towards pharmacies adopting social distancing measures. We have provided personal protective equipment free of charge; this provision has just been extended to March 2022. We have also reimbursed community pharmacies for PPE purchased previously. We have provided non-monetary support, such as the removal of some administrative tasks, flexibility in opening hours, support through the pharmacy quality scheme for the sector’s response to Covid-19 and the delayed start of new services.
Between April and July 2020, a total of £370 million in extra advance payments was made to support community pharmacies with cash-flow pressures due to Covid-19. These cash-flow pressures were caused by several issues, including a sharp increase in prescription items in March and April 2020, higher drug prices, delayed payments from the pharmacy quality scheme and extra Covid-19-related costs incurred by the sector.
Acting quickly and providing the sector with £370 million in extra advance payments helped alleviate immediate cash-flow concerns. It also gave the Government time to address the causes of the cash-flow pressures. I hear the calls from the noble Lord, Lord Hunt, for the Government to write off this money and for further financial support for this valued sector, but our healthcare system is under huge financial pressure. We do not have a limitless supply of funds, so I cannot make the commitments he asks for.
I reassure my noble friend Lady Wheatcroft that community pharmacies have been paid for the increased items they dispensed. Reimbursement prices have been increased to reflect higher drug prices, and payments have been made under the pharmacy quality scheme. However, the department is still in ongoing discussions with the PSNC. To reassure the noble Baroness, Lady Thornton, these will cover the reimbursement of Covid-19 costs incurred by community pharmacies. I reassure noble Lords that the Government will take a pragmatic approach. I expect any agreed Covid-19 funding to be deducted from the £370 million of advance payments to be recovered from community pharmacists.
As my noble friend Lady Wheatcroft put so well, in England the 11,192 community pharmacies have played and continue to play a vital role in the response to the pandemic. We need community pharmacies to be financially sustainable to continue to do so, whether for everyday care or in emergencies. I am aware of concerns that the current funding is not enough. The department wants to work with the sector to look at this in more detail.
I have absolutely heard the concerns of the noble Lord, Lord Hunt, about pharmacy closures. I reassure noble Lords that we are monitoring the market very closely. Our data shows that, despite the number of pharmacies reducing since 2016, it must be recognised that there are still more pharmacies active today than there were 10 years ago. Proportionally, the closures reflect the spread of pharmacies across England, with closures tending to be where pharmacies have clustered. We monitor these closures closely. In the most recent 12 months we have data for, we saw that three-quarters of the closures were of pharmacies that were part of large chains. This data aligns with the consolidation announcements by those large chains before the Covid-19 pandemic.
Government data also shows that the increase in homeworking during the pandemic has led to a change in the pattern of pharmacy use, with more people making use of community pharmacies local to where they live. It is important that we protect this access to pharmaceutical services. Therefore, our pharmacy access scheme protects access in areas where there are fewer pharmacies and higher health needs so that no area is left without access to local, physical NHS pharmacy services.
We are about to begin negotiations with the PSNC over service developments for this financial year, having recently shared our proposals. They are confidential negotiations; I will update Parliament once they conclude.
The past year has been extraordinarily challenging for the NHS, including for community pharmacies. They have risen splendidly to the many challenges brought by the pandemic and have shown great resilience. We expect 2021-22 to be the year in which we recover from the pandemic and build on the work already achieved in the previous two years of the five-year deal. Our plans and proposals take the impact of Covid-19 on the sector into account, in terms of both the challenges and the opportunities the pandemic has presented.
In response to the questions from the noble Baroness, Lady Brinton, on the current negotiations, I reassure her that the upcoming negotiations between the department, supported by the NHS, and the PSNC are the opportunity for the sector to raise concerns and discuss what can realistically be achieved. When we talk about the funding of community pharmacy, it is important to recognise that Covid-19 is also an opportunity for it. I completely agree with the noble Baroness, Lady Barker, on the new ways of working. The pandemic has shown us the value of our incredibly highly skilled community pharmacy teams, and how they can contribute more and receive more funding as a result.
For instance, we commissioned community pharmacies to operate the medicine delivery service for shielded patients. This has been vital to help ensure that the vulnerable in our communities continue to receive their medicines safely. This has since been extended to people who are self-isolating. Another example is that we have delivered our biggest vaccination programme ever because of Covid-19; community pharmacies have vaccinated more people than ever before. Some 300 pharmacy-led Covid-19 vaccination sites are currently live and we are, of course, considering the important role that community pharmacy can play in future phases of the programme. In addition, community pharmacies are now offering a lateral flow distribution service, Pharmacy Collect, making those tests readily available at pharmacists across the country. It is proving extremely popular. These are examples of how community pharmacy is supporting the fight against Covid and how the Government are making better use of the clinical skills of pharmacists, while giving community pharmacies an opportunity to generate more income above the £2.6 billion per year in the five-year deal.
In conclusion, this Government completely understand the value of community pharmacies and this Minister most definitely does. With four children, I am utterly dependent on the Nashi Pharmacy on Westbourne Grove by day and the Bliss Pharmacy at Marble Arch by night. I pay personal tribute to the thoughtfulness and clinical insight of those important resources.
I understand the noble Lord wanting to use every opportunity to raise this important issue and to ensure that community pharmacies are adequately funded. This issue was debated in the House of Commons only last month. I can reassure noble Lords that the Government have heard the concerns expressed today. We are committed to working with the sector on a sustainable funding model for all community pharmacies. We are about to enter negotiations with the sector about what it can deliver this year. I hope that this reassurance is sufficient for the noble Lord to withdraw his Motion.
Lord Hunt of Kings Heath (Lab) [V]
My Lords, this has been a very good debate. I am grateful to all noble Lords, and the Minister, for their interesting contributions. Although this was essentially about the funding of community pharmacy, the huge contribution that it makes—and can make in the future—became very apparent in this debate. I hope that this is what will draw us together.
The noble Baroness, Lady Barker, drew an interesting distinction between provision in south London and that in south Lancashire. The irony is that it looks as though community pharmacies are most vulnerable in the most deprived areas and we really have to deal with this.
I was interested in what the noble Baroness, Lady McIntosh, had to say about dispensing doctors. When I was the Minister responsible for community pharmacy 20 years ago, we established a joint committee, between the PSNC and the BMA, of community pharmacists and dispensing doctors, to try to resolve some of the tensions. I am not sure whether we succeeded in doing that, but I echo the noble Baroness’s comments about the role of dispensing doctors.
I also thought that the noble Baroness, Lady Wheatcroft, gave an interesting analysis of the financial challenge facing the sector. She and the noble Baroness, Lady Brinton, referred to the EY report. What she said about the general impact that community pharmacy has on high streets was very important and we should not forget it.
We should also not forget what the noble Baroness, Lady Brinton, said about the unsustainable financial framework for many community pharmacies at the moment and the Government’s consultation and recommendations for structural financial change. I also echo what she said about resources for training pharmacists in new services.
In her winding, my noble friend Lady Thornton made the important point that community pharmacies did not close; they carried on and were of huge benefit to us. That is why it is so frustrating that there are so many local examples of where the NHS does not see the potential of community pharmacy. I come back to what I said earlier about the need to ensure some kind of statutory provision for community pharmacy representation around board tables, at local level. You could say the same for opticians and dentists; all too often, they are neglected by the decision-making bodies. When we no doubt come to debate these matters on the Queen’s Speech, in a couple of weeks, I hope we come back to the structure of the future NHS that the noble Lord wishes to bring us.
The noble Lord, Lord Bethell, chided me a little, I think, about using this SI as a way of raising general issues, but what are we to do? We have largely been deprived of Questions for Short Debate over the last year, and I am afraid that this SI is an excellent vehicle to raise more general issues. I have no problem whatever with the SI before us. I am grateful to the Minister for saying that he has heard my concerns and that there are discussions and negotiations going on, and that he will report back to us. But—and it is a big “but”—there is a tremendous risk that we will undermine the very fabric of community pharmacy unless we take action, which is what I urge on the Government. Having said that, I beg leave to withdraw my Motion.